December 26, 2010

The final version of the health care legislation, signed into law by President Obama in March, authorized Medicare coverage of yearly physical examinations, or wellness visits. The new rule says Medicare will cover “voluntary advance care planning,” to discuss end-of-life treatment, as part of the annual visit.

Under the rule, doctors can provide information to patients on how to prepare an “advance directive,” stating how aggressively they wish to be treated if they are so sick that they cannot make health care decisions for themselves....

Get ready to be prompted to sign a document that will sound helpful and reasonable. The advance directive. Don't you want the autonomy and control that comes from deciding in advance that you don't want people to try to save your life?

“While we are very happy with the result, we won’t be shouting it from the rooftops because we aren’t out of the woods yet,” [said the office Representative Earl Blumenauer of Oregon*] in an e-mail in early November to people working with him on the issue. “This regulation could be modified or reversed, especially if Republican leaders try to use this small provision to perpetuate the ‘death panel’ myth.”

Moreover, the e-mail said: “We would ask that you not broadcast this accomplishment out to any of your lists, even if they are ‘supporters’ — e-mails can too easily be forwarded.”

The email said email can be too easily forwarded. Ha ha ha. And now, here it is, quoted in the NYT, cut and pasted into blogs.

The e-mail continued: “Thus far, it seems that no press or blogs have discovered it, but we will be keeping a close watch and may be calling on you if we need a rapid, targeted response. The longer this goes unnoticed, the better our chances of keeping it.”

In the interview, Mr. Blumenauer said, “Lies can go viral if people use them for political purposes.”

But it's not a lie. You may not like the label — no labels! — attached to the policy, but the policy itself is understood — understood and presented in an inflammatory way that precisely counterbalances the soothing, lulling tones used by people who like it.

Sarah Palin, the 2008 Republican vice-presidential candidate, and Representative John A. Boehner of Ohio, the House Republican leader, led the criticism in the summer of 2009. Ms. Palin said “Obama’s death panel” would decide who was worthy of health care. Mr. Boehner, who is in line to become speaker, said, “This provision may start us down a treacherous path toward government-encouraged euthanasia.” Forced onto the defensive, Mr. Obama said that nothing in the bill would “pull the plug on grandma.”

Well, you will pull the plug on grandma, but only after grandma has signed the document the doctor explained to her long before she got into the situation she's in now, back when it seemed like autonomy and control.

“Using unwanted procedures in terminal illness is a form of assault,” [said Dr. Donald M. Berwick, administrator of the Centers for Medicare and Medicaid Service].

The question is what do patients want and how what they want will be determined. It seems to me that the effort is to get people to commit in advance to death-hastening choices, by getting everyone to sign these documents. Now, all the new regulation seems to do is to authorize Medicare reimbursements for the time health care professionals spend counseling patients about the value and importance of signing the document. It's hard to see what's wrong with that. If treatments are covered but advice about forgoing treatment is not covered, then there's an incentive to do expensive things.

In a recent study of 3,700 people near the end of life, Dr. Maria J. Silveira of the University of Michigan found that many had “treatable, life-threatening conditions” but lacked decision-making capacity in their final days. With the new Medicare coverage, doctors can learn a patient’s wishes before a crisis occurs.

Treatable? You have a condition that can be treated, but you can't think well enough anymore to decide whether you'd prefer to die? If you've signed the document, the answer is you'd rather let the condition kill you, because you allowed the doctors to "learn [your] wishes before" this "crisis" occurred. You didn't know what the crisis would be or how you would feel when it happened, but you had "wishes" then and these will be taken as your "wishes" now.

138 comments:

People can sign advance directives now, if they want to, but you seem think that making them more informed about this option is: a) bad; or b) the first step toward government telling people what care they may not get.

As to the first point, isn't this the same argument made when people don't want to give out condoms, clean needles, sex education and papillovirus (sp?) vaccinations because they may, at the margin, increase unwanted behavior?

If you reject that form of argument on other issues, don't embrace it now without a real good reason.

An advance directive could have cut through a lot of crap for Terry Schiavo, too. The idea is that we all know we could wind up in a situation where we cannot make our wishes known, or where our capacity is gone or under question. No one pays much attention to such a directive where a plainly lucid and communicative patient requests treatment.

Advance directives have the potential to alleviate the torture that family members go through when they ARE asked to decide whether to pull the plug on Grandma, and if you have elderly parents, you may well long for its succor. That, by the way gets to a legitimate potential drawback for the process, which is that younger family members will pressure relatives to execute such directives. But that risk existed long before Obama was even nominated.To think that some unfamiliar doctor distributing information on the procedure will somehow pose more of a threat of unduly influencing a person to sign such a directive seems to miss the point of how important the issue is within families.

I sat in on part of the hour-long visit my in-laws spent with their doctor going over my father-in-law's care directives.

It was a significant part of helping my mother-in-law come to terms with what was happening. It let my father-in-law make decisions that helped us care for him, according to his wishes, over the next two months.

Could he have pursued more aggressive treatment? Probably, some doctor somewhere would have signed off on another round of chemo, but the last two rounds didn't impact the tumors and nearly killed him, he and his doctor decided not to pursue treatment any more.

It is strange how private companies denying care was the worst thing any human being could possibly do and the impetus for government takeover of 1/6 of the US economy.

However, the same people who can't stand the idea of an evil corporation denying care seem to have absolutely no problem with a government bureaucrat doing so or enacting all sorts of legislation and 'solutions' to encourage people to 'choose' to die rather than use up expensive treatments.

Its really sickening. If an HMO was doing exactly this, leftist groups would be protesting 24-7. Since its 'the government' though, everything is fine, get in your coffin citizen.

Advance directives are patients letting their family and physician know what kind of treatment they want or don't want under certain conditions, if they are incapable of making that decision themselves when the situation arises.

"Death panels" are government bureaucrats telling your doctor what kind of treatment you can or cannot have, based on their judgment on the cost effectiveness of allowing you the treatment. Some will say, "Well, insurance companies do that now!" but you have the option of changing your insurance company. You won't have the option of choosing a different government "death panel" if they come into existence.

To summarize: Advance directive = patient choice. Death panels = government choice. Do you trust your government to make THAT choice for you? Remember, they'll have gold-plated government health plans that will give them whatever they want. They and their families won't be subject to the death panels.

My doctors at the University Hospital have asked me to fill out a living will which includes advanced directives, I am 68, and I helped my dying mother to set up her advanced directive at the age of 92. Like Peter it seem to help her come to terms with the end of her life, and for me I feel that I will have some control over the quality of my life should my life not end suddenly but linger in an limbo of no real cure.

Lucien: Advance directives are fabulous so long as they are not encouraged by a system that stands to gain by one particular directive. How fabulous would it be if every "directive" said to keep the patient alive at all costs, using every available technology? Do you think that might not be what they have in mind up there at the central insurance agency dealy?

Clyde: You are mostly right. But if the government has much to say about what the doctor gets paid is it not in the doctor's interest to use his powers of persuasion to have the "directive" mirror his economic interest? If you only get paid a very little for providing end of life treatment would it not be better if the life ended a bit earlier?

I await the blogger's equally shrill diatribe against the supposed injustice of life-insurance policies.

Althouse's War against End of Life Directives is an example of how out of touch the GOP has become. A new saga in the war against reality has been launched with this quixotic battle of hers (and Palin's) against mortality. Not through medical or technical means, of course. Instead, this is an existential or allegorical battle against mortality, for political purposes.

People can sign advance directives now, if they want to, but you seem think that making them more informed about this option is: a) bad; or b) the first step toward government telling people what care they may not get.

As to the first point, isn't this the same argument made when people don't want to give out condoms, clean needles, sex education and papillovirus (sp?) vaccinations because they may, at the margin, increase unwanted behavior?

They're anti-information, Lucien.

Ignorance makes them feel freer than they really are.

They think that being misinformed about how they go about dying will make them live longer, for chrissakes. Perhaps even forever.

My uncle passed away December 12. He was a great man, not a term I use lightly, and I would be a much much better person if I had one-tenth his character.

He died of a very aggressive lymphoma which was not definitively diagnosed until about four days before he died, and by then he was too far gone mentally to assimilate the diagnosis and its implications.

He had named me his agent for power-of-attorney purposes, and he had signed an advanced directive which stated:

"I do not want efforts made to prolong my life and I do not want life-sustaining treatment to be provided or continued (1) if I am in an irreversible coma or persistent vegetative state; (2) I am terminally ill and the application of life-sustaining procedures would serve only to artificially delay the moment of my death; or (3) under any other circumstances where the burdens of the treatment outweigh the expected benefits. I want my agent to consider the relief of suffering and the quality as well as the extent of the possible extension of my life in making decisions concerning life-sustaining treatment."

The same form also had check-the-box choices for "give me life sustaining treatment unless I am in a vegetative coma or persistent vegetative state" and "give me life sustaining treatment no matter what." Plus it had a space where you could write your own statement from scratch. And the preamble to all that was a grant of authority to me (not the government or the physicians) as his health-care agent of "full power and authority to make those decisions for me, subject to any statements of desires or limitations set forth below."

He executed this first in 1992, and then reaffirmed it in the Spring of 2010, when still of sound mind.

Anybody want to guess how much comfort and reassurance this document provided me as the one having to make life-or-death decisions on his behalf?

Is the preferred alternative not having a means to know the wishes of the patient when the time comes?

First of all, it must be noted that advanced directives and "living" wills and healthcare power of attorneys are NOT within the province of the practice of medicine which doctors should be giving advice for. These are LEGAL documents. Doctors should NOT be giving legal advice, they should NOT be practicing law.

To sign or not sign, to even suggest or offer the above legal documents is something to discuss between a person and her LAWYER.

Secondly, the way nearly all of these things are written is to preclude and prohibit the provision of medical care. Not only is the language in these documents expressly tilted toward death, not life, but the language is typically so ambiguous and open-ended that it ends up giving the doctors and bureaucrats total control over to let you live or die (e.g. using subjective terms like "extraordinary" or "futile" without defining them).

The reason that these things are so tilted against treatment is that they were and are pushed by the right-to-die crowd. These are the same people, who have infested medicine, who would have people believe that food and water constitute "medical treatment," and that to withhold them, to starve and dehydrate someone is not to kill them, but is merely to let the underlying dying process proceed.

If you absolutely must have one of these things, then you must have it drafted by a lawyer -- there is a lot of LEGAL language in these -- and you must insist on defining every tiny little term, so that you don't end up having someone in a position of power who wants to kill you having the power to do so. Be sure you include language that not only specifies when treatment is to be withheld, but when it CANNOT be withheld, but instead must be provided.

The far more preferable document is NOT the advanced directive, but the healthcare power of attorney. With the advanced directive, doctors decide when it does or does not apply. And if there is a dispute, then judges decide. DO NOT LEAVE YOUR LIFE IN THE HANDS OF A JUDGE. Instead, sign a healthcare power of attorney that appoints some person you trust with your life to make those decisions for you.

Here's a little bit of trivia for you folks out there --

After leading the charge to cause the death of his daughter, the father of Nancy Cruzan languished in depression before finally committing suicide.

“treatable, life-threatening conditions” but lacked decision-making capacity in their final days.

Am I missing something? What does "treatable" mean? If it means "make you better and send you home" why would an Advanced Directive even come into play? If "treatable" means "cure the the illness but leave you a zombie" I would understand this better. Lots of wiggle room for doctors, hospitals, and other care givers whose funding depends on cutting costs to push for no treatment. This sound like we will need specialized lawyers to help us out!Jim

Advance directive: when done voluntarily by the family and with the consultation of their own lawyer and their own doctor does = patient choice

Advance directive: A)when funded by the Government and when doctors get PAID to encourage such advance directives. The more they do the more they get paid.B) when encouraged by the Government when the patient is a Senior Citizen and can easily be swayed by authority figuresC) when there is a Governmental interest, money not paid out for Grandma's care

Personal testimonials might test Althouse's intestinal fortitude. Remember, politics for her is a magical fantasy land where arguments exist in thin air, for their own sake, and not because they have any impact on people, their lives, their emotions, their finances, or any of that sort of thing.

Clergy have been replaced by the medical industrial complex, and life everlasting now exists in hospital beds, with respirators, intravenous fluids, narcosis-inducing pharmaceuticals and a family of guardians chained to the bodies they must decide on - with every daily, weekly and monthly bit of bad news from a physician - how to maintain in perpetuity. Welcome to the future as Althouse would have it.

One more piece of evidence that some Republicans are choosing to become more and more like robots.

I'm all for INFORMED consent. And I'm all for advising people of their LEGAL rights. But such advice and the action of obtaining true and complete informed consent needs to be from someone who does not have a complete conflict of interest, such as doctors and other healthcare workers.

Indeed, another major problem with advance directives is that they are a gross violation of informed consent. As their name indicates, they are signed in ADVANCE before a person has all the relevant information he or she needs in which to make a medical decision. This is not informed consent, this is ignorant consent, this is hypothetical consent.

Moreover, especially when one has been written and signed years ago, a person's intent may very well have changed over the years, he or she may now want treatment in certain situations and not want it in others (which again are wholly speculative and without complete information). But they may find themselves locked into some 10-year-old document. If they find themselves choking on a piece of chicken, they may want someone to help them dislodge it -- too bad, they signed a DNR years ago, when they ignorantly saw some "vegetable" on TV and quickly decided they wouldn't "want to live like that."

By all means, let's have real informed consent. Let's tell people the FULL ramifications of things like ObamaCare before they are passed and not, let's pass it so we'll know what's in it. And let's repeal the damn thing since the people have overwhelmingly said that they do NOT consent to it.

And, finally, for all you pro-abortion types who no doubt advocate this -- let's get government out of the doctor-patient relationship. What they say or do not say between them is none of the government's damn business.

Yes, these are not "death panels" anymore than a Living Will is a "Death Panel." As is pointed out here by others, the true "Death Panels" are those Govt panels (there are at least two, iirc) under Obamacare which are set up to rationalize "best practices" on a cost-benefit analysis basis for Physician/hospital approved reimbursement schemes/formulas. The British NHS already has such an animal (NICE) which forbids open-heart surgery on those over age 65 iirc as well as no kidney dialysis for those over age 55. "Utilitarian" will be the key word going forward if Obamacare remains standing..but of course, as usual, this will only apply to the "little people." The rich will be able to "opt out" by going overseas/across the border to Mexico, Caribbean , India, Thailand, etc,. while the Nomenklatura will carve out "Level 1" tax-payer-funded care for themselves merely by extending the federal health plan Congress and the Federal bureaucracy/Civil Servants (some "servants") already enjoy. the rest will be left to the tender mercies of Medicare/Medicaid and County health services characterized by long waiting times and indifferent/incompetent service/care.

The State of California and the SEC have numerous and onerous rules just for selling insurance products to Seniors, which are people who are 65 or older.

Just to meet with a client or to suggest that one investment be sold to buy a new investment at that decrepit advanced age (snark alert) the agent or broker has to have them sign multiple documents and go through several layers of compliance review.

This is to make sure that the poor addlepated "senior", who is supposed by the Government to be incompetent to make these financial decisions, won't be taken advantage of by the greedy insurance agent (as has often happened)

All these precautions are about the supposed incompetence of the senior to decide about their money.....YET....we want to take the same addlepated 'senior' and guide/coerce them, without precautions to make decisions about life and death??

And, finally, for all you pro-abortion types who no doubt advocate this -- let's get government out of the doctor-patient relationship. What they say or do not say between them is none of the government's damn business.

No doubt you prefer having insurance companies telling you how quickly they think you "should" die when they're paying the bill.

That's fine. Can we have the insurance companies printing the money for funding and treating such financially exorbitant persistent vegetative states too, then?

If you want to maintain, incubate and perform heroic measures on your own pet vegetable, that's fine. Please make sure you provide funding up-front, first, though. And in cash. Because it's fucking up the ability for others to afford ACTUAL care. You know. Care for the living and breathing.

Bender is right. Most of the advance directive documents (all of them in Ohio) lean strongly toward the language of doing nothing. I have never seen a document like the one Rich describes, with choices for aggressive care included. Perhaps his uncle had an attorney customize one for him, or perhaps he lives in a more enlightened state. Here in Ohio most people use a standard document that I believe was designed by the state. Their choice is to sign or not to sign. If they want treatment, they don't sign one.

Discussing advanced directives with your physician is a good idea, but it should come with no financial strings attached. The best place is in your personal physician's office before you become seriously ill and while you still possess all your faculties. Once you end up in the hospital and can no longer speak for yourself, all kinds of value decisions about your life will be made for you, usually by doctors who don't know you. I have seen this too many times in the hospital to ignore. The specialist will push for a DNR status on an old smoker who drinks more than is good for him, even in cases where the guy is adamant he wants ventilator support if he needs it. They are more concerned about taking up limited ICU space caring for the guy than by trying to do right by him. I often have to remind our ICU service that the DNR choice is the patient's to make and that we are obligated to honor that choice.

Another thing about paying for advance directive discussions, is the impact it will have on non-Medicare patients. Once doctors get paid for ser vice that they usually do for nothing, they will start charging everyone for it. Eventually, they will expect to get paid for having these discussions. Once again the poor and uninsured will get screwed.

Few, very, very few people are truly of the mindset to provide treatment "no matter what." When a person is truly "dying," then to hold off the inevitable would be not only be an inappropriate denial of medical truth, but would be a denial of ontological truth, that this world is not the be all and end all of existence. The true pro-life person is not merely pro-this-life, but pro-eternal-life as well. To cling to this life is to deny the very existence of God and heaven. One should not unduly prolong the process of dying.

But the problem is that various ideologues wish to redefine what constitutes "dying" to include more and more people who are quite alive, e.g. persons in a persistent state of unconsciousness. The problem is that they want to hasten death, to bring it before its time.

If this is such a great idea, why were its proponents so intent on keeping it quiet?

The reason is precisely the conflict of interest noted by several commenters. The state benefits by encouraging advance directives. Imagine if a private insurance company had this policy.

The far better option is to trust your family to understand your wishes and do the right thing. If you are concerned that the docs will not listen to your family members out of concern for their own liability, have a medical power of attorney that clearly grants the authority.

And do consult a lawyer, and perhaps your local priest or minister.

I managed these decisions during the last care of both my wife and mother. This is not an easy job, but it's better to be able to exercise discretion as conditions change, and far better to have the family member and not the doctors making the decisions. Even with advance directives, the doctors are very reluctant to make these decisions, as well they should be.

Not noticing Bender's post until I posted mine, I must say that I am in full agreement with him on this. The legal aspects of a living will are much preferred to that of the medical advise under discussion--which is why so many--not without fear as seen by precedent--worry these are but the camel's nose, so to speak. But the REAL "Death Panels" are ALREADY embedded in ObamaCare in the form of the "best practices" ones which is Death Panel by WHOLESALE, rather than the retail medicine these procedures under discussion/worried about here potentially represent insofar as treatment would be denied *a priori* to broad categories of people based on purely cost-benefit budgetary analysis

The more vegetables we keep under incubation, the more premiums will rise, the more we can deny basic care to those indigent who are still alive and kicking, and the more we can scapegoat the government for spending inefficiently.

What this comes down to is a war against the poor and middle class, at base. This discussion shows that even vegetables are more important to the GOP than the poor and middle class - whether assisted by the government or even middle class citizens with private insurance.

Virgil is right about the real death panels. The best practices will be chosen for their ability to save money. What a lot of people dont't realize is that stimulus bill included provisions to penalize doctors if they don't adapt electronic medical records which will 1) communicate your health record information directly to the state and 2)enforce the adoption of these best practices at the point of care. Sounds totally nuts, but it is true.

If you really want to understand the problem with the government's position on this, read the little booklet that justified euthanasia of "unfit persons" in Germany and gave carte blanche to what was to come under the Nazis. The Release of the Destruction of Life Devoid of Value by Hoche and Binding published in 1920 uses "logic" to move from the voluntary release of one's life to the point at which a "doctors' committee" is allowed to make the decision if the patient is no longer has the mental capacity to choose. From there it's just one little step to making the argument that mentally handicapped people do not have the mental capacity to choose, and of course, if they could choose, wouldn't they choose not to be a burden on others? Next step, extermination for the "mentally unfit", and that whole process desensitized the doctors to the point that they were prepared for mass extermination of the the Jewish population. All they had to do was create a new expert approved language to describe who was unfit or "subhuman". We see this language game also used today on "fetuses". Isn't it easier to do away with an "unwanted fetus" than it would be to do away with a little human baby?

"I have never seen a document like the one Rich describes, with choices for aggressive care included. Perhaps his uncle had an attorney customize one for him, or perhaps he lives in a more enlightened state."

It's a fill-in-the-blanks and check-the-boxes form from the California Medical Association.

This is something that is so incredibly open to abuse if doctors become government functionaries, as Dr Berwick wants. The idea of the doctor as used car salesman trained in high pressure tactics has red flags all over it.

Bender is correct. This is legal, not medical, and a lawyer ought to be present when anything like this is discussed.

Trickling Down His Leg said...

The bias on this thread against non-vegetable based lifeforms is showing.

Ever dealt with an end of life situation?If you have, then you understand that planning is part of the process. Another weird part of American exceptionalism.....non-stop medical interventionno matter the age or prognosis.

When one of the parties to the advanced directive conversation has a financial interest at stake, like Medicare or the hospital or doctor, trouble will surely follow.

I am sure that HHS will penalize doctors and hospitals who "overtreat" or otherwise disregard the other regulations and procedure "guidelines" and price controls. Is it a death panel yet? Maybe not, but it's getting there.

You're being too hard on my newest incarnation, VX - and besides, who can trust your motives? But I definitely had some much pithier and zanier humor to dispense last week. TG, who is a much more objective judge of these things, said so himself. They were just detached, witty and goofy enough that I felt even Althouse herself might have approved.

Anyway, as every good conservative (and physician) knows, effective things often are banal. I wish you could stand to lose this argument more gracefully, but as with the topic at hand, perhaps refusing to acknowledge the reality of the matter is the whole point.

This is horrible that professional Journalists are allowing Death Panel news to seep out. Don't they know that the State says that these Panels are not real,but only a figment of luddite Alaskans imaginations.

A man with as much to learn as you do should become used to being amazed by now.

Anyway, anyone living through the aughts ought to be pretty used to spectacle and mystery overcoming bright lines of political division. George W. pretended to enact liberal (or as he called them, "compassionate") policies and Breitbart has his whole collection of "big" this and "big" that sites. Conservative fixations of power over the last ten years have turned partisanship into a joke and ideology into farce, so it's best you learn to deal with issues of identity and face your sorry inability to attack an actual argument head-on.

Democrats simply will not allow such facts to enter this debate. However ...

Hospitals are, in point of fact, one of the leading causes of death in the United States. More than 48,000 people died directly because their presence in a hospital killed them.

Had these people not been in the hospital in the first place, these people would not have died of the diseases that killed them.

That makes hospital-caused homicides the fifth leading cause of death in the United States ... just behind car accidents.

These are not people who were otherwise sick, went to a hospital and died there. These are deaths directly caused by the poor care they received in the hospital - mostly from hospital-caused infections of sepsis and pneumonia.

Hospitals are infectious disease breeding grounds. You're a moron if you voluntarily go into one. And you're just asking to let them kill you if you do go into one.

But don't believe me ... it was reported by the Wall Street Journal and the Centers for Disease Control.

The ethos of being an American is to lend aid to the weak and the dying. We are not abandoners. That is why the leaders in Death Care here must be imported from Europe or Kenya. The Tea Party has seen the evil aimed at them at age 70--65--60--55--50 and they are fighting that as they should. We are not surrender prone kenyans.

Democrats simply will not allow such facts to enter this debate. However ...

Hospitals are, in point of fact, one of the leading causes of death in the United States. More than 48,000 people died directly because their presence in a hospital killed them.

You're still safer here than in one of the Third World style Euro hospitals Berwick and The Zero want to establish in this country. In terms of percentages, I'm guessing 48 grand is fairly low against the number that went in and out yearly.

And, via Instapundit, there's this lesson in state-run legal immunity when they mistreat you and kill you that appeared in the Christmas Eve issue of the NY Times:

http://www.nytimes.com/2010/12/25/nyregion/25damages.html?_r=1&hp

A hospital of any kind is the last place you want to go. You stand a really good chance of dying there because the owner of the hospital and its employees run it so poorly that you are killed merely by being there.

"The professor doesn't have an advance care directive, at her age? I wish my brother had had, when he was felled by a stroke at not-quite 50 years old. I had to make his final care decisions for him."

No, I don't. I want a human being who cares about me to deal with the actual situation when it is really at hand. I don't want to imagine endless possibilities when I'm not in the perspective of facing them and make generalized decisions. I don't think that's the best way do deal with life.

Choosing to make an advance directive is fine, but why should it be subsidized by one's neighbors any more than making a will is subsidized?

Because the government wants you to cost less money rather than more. The default is to give treatment rather than withhold it. So, the more people can be induced to officially choose less treatment, the better. And for those who don't choose less, there are other ways. Thus Britain, and now the U.S., is against government funding for certain spendy cancer treatments.

If Terri Schiavo is any indication, the most barbaric ways of "allowing people to die" based on advance directives will be implemented. Depriving an animal of food and water is rightly against the law. But, depriving a human being of food and water until they die is officially okay.

1. First, they will try to talk Republicans into dying before elections, and keep Democrats alive until they vote.

2. Soylent Green will be the biggest new industry created under Obama's watch. Sausages of your relatives available at lower prices.

3. At present, you can't just ask for the Oregon medics to kill you. They won't do this. But in the future, they might ask your political party, and if yours don't agree with theirs, you can be liberated, as long as you donate your money to their partyy.

Interesting legal problem here. Legal documents being signed without legal counsel. Next time I go through check in (hopefully with someone else), I will look into this a bit more.

The problem is that though I am theoretically a lawyer, whenever I have helped someone go through check-in, they are always in so much of a hurry, that I am not given a chance to review what that person signs. But I do know that you have to initial a lot of things, indicating that you supposedly had read them.

But what is a bit humorous from a legal point of view is that this person cannot see well enough (thanks to some medical malpractice) to know where to sign (or, to read the forms, for that matter). So, I would place this persons hand in the correct position, and they would sign or initial, as required. All before the hospital admissions person.

I would say that this was an anomaly, but it isn't. It has happened at two hospitals that I can remember. One a big county hospital in a large city, and the other in a small private hospital.

And, yes, they always, always, ask for advanced directives, and seem a bit put out when the response is that there is a durable power of attorney in place.

Some lawyers are going to have fun with this down the road, after a hospital lets someone die because they signed something under pressure from a medical provider, when they weren't warned to get legal representation. Maybe something for the profession to do, once all the doctors are unsuable for malpractice because they work for the government.

I went through the last illness of a relative, and his passion for life at the end made him call for all measures possible to save him when the doctors asked him how far he wanted them to go. His heart attack was too massive, though. At least we know he and the docs gave it their all and he went out fighting. "Do not go gentle..."

I think that depends on the situation, but that is why you have someone making the decision for you, and visa versa.

My mother died of ovarian cancer at 80 after a good life. After the last chemo put her in a wheel chair, there wasn't a lot left to do. The end was fairly quick, when it came. A week or so in hospice. And, all they did, or really could do, was give her narcotics for the pain.

This was the sort of situation where you really didn't want heroic measures.

On the flip side though, a friend of mine's mother had a brain aneurysm. She was in a coma for a couple of months. But, she eventually came out of it, and that was more than a decade ago, despite losing some of her mental facilities. By all indications, she seems relatively happy. And, yes, this friend was repeatedly told that they should stop life support during the time that the mother was comatose.

So, I think that I am like Prof. Althouse here. A person whom you can trust in this sort of situation is far better than leaving it up to doctors, and, worse, maybe ultimately, the government.

I don't like Obamacare, but I think some people are living in a fantasy world right now. This already happens every day. It happens to young people who have terminal illnesses, it happens to the very old who probably won't survive the treatment...or if they do not for very long.

We have advanced directives, hospice and living wills.

I work for a home health care agency and I have been there when people died and have seen this sort of thing many times.

I am amazed that so many people on the right who have done nothing but complain about Medicare Part D would decide to get upset about this. They don't want to help some old lady by her meds, but they complain about some socalled death panels...when the truth is these decisions are made every day by insurance companies, medicaid, and veterans affairs as well as private practice doctors.

I think though that the reality here, as far as hospitals and medical care providers go is a bit more subtle than we are making it out.

My guess, being a paranoid attorney, is that advance directives are being pushed so heavily by medical care providers because of the problem that many people aren't willing to let go, or more importantly here, let their loved ones go.

So, the doctors and hospitals are faced with a problem. Their natural inclination is to do whatever they can. But at some point, they have to pull the plug. And, they don't want to be second guessed here. Esp. from a legal liability point of view. Maybe if they had tried just one more thing, with a 1% chance of success, the patient would have survived.

The real problem though is that in the past, they could usually expect to get paid for this heroic last minute stuff, if they pushed as far as they thought possible.

But we are entering into new territory here, with the government being the party determining, to a good extent, when to stop paying. And, the dynamic is going to be a lot different. Many medical care providers likely believe that they will need this sort of legal protection for when the government mandates that funding for care is cut off.

I am amazed that so many people on the right who have done nothing but complain about Medicare Part D would decide to get upset about this. They don't want to help some old lady by her meds, but they complain about some socalled death panels...when the truth is these decisions are made every day by insurance companies, medicaid, and veterans affairs as well as private practice doctors.

Of course they are made every day. But right now, there is a limit on how far insurance companies and doctors in private practices can go in this area. And that limit is imposed by their legal liability for denying treatment that they should have, arguably, paid for.

The problem is that the government has only so much liability in this area as it allows. If and when it doesn't want to be sued for medical malpractice, or for intentionally withholding treatment for monetary reasons, it can, at some level, just decide to exempt itself. It is called "sovereign immunity".

I, for one, look to Canada, and, esp. to Great Britain, to see the logical conclusion of this. You mean that I can't get dialysis because I am over 55? Dialysis is bad, but the alternative is far worse. A friend of mine was on dialysis for a couple of years, right around the 55 cutoff, and then got a new kidney. It was like a light got turned back on for her. She went from looking 60 to less than 50 now.

Terri Schiavo wasn't dying, she was killed. A rather big difference. And by whom? An ex-husband who wanted to get his hands on an insurance settlement that was awarded to support her as long as she lived. No one knows what she would have wanted and even if at one point that she would have preferred to not have extraordinary life saving measures doesn't mean that she might not have changed her mind. What we do know she was judicially killed by starvation and dehydration for the purpose of granted her ex-husband a chunk of change.

As for the arrogant ass who is posting as conservative whatever-the-hell it used to call itself,do the world a favor and die today but do so in an environmentally and Gaea friendly way. You have an amazing ability to get conservative minded people to reconsider abortion; just how much better the world would be if your mom had one.

Untrue. Insurance companies do not decide when to withdraw care. Nor does Medicaid or the VA.

Doctors sometimes do, when futility is present.

Pogo - the problem here is that if and when the government starts making funding issues in this area, it is going to be very hard for the doctors to resist this pressure. I know that all doctors are extremely heroic and well intentioned, almost saintly in their demeanor and their every action. But, they too have to pay mortgages and send their kids to college. And, even if, through their innate nobility, they were willing to work heroically beyond what the government was willing to have paid for, the hospitals are still going to demand payment. And, this fact, unfortunate as it is, is going to ultimately have an impact on the limits that doctors are willing to go.

On the flip side though, a friend of mine's mother had a brain aneurysm. She was in a coma for a couple of months. But, she eventually came out of it, and that was more than a decade ago

Same thing, except it was my mother. She was in an auto accident and had severe head trauma. The Dr.s told us first, that she wouldn't live, then when she was in a coma for over 6 months, that she would be a vegetable and that we should give up.

However, she recovered and went on to live for another decade and got to see her granddaughter born, traveled to Costa Rica and Europe. Had we listened none of this would have happened.

She was utlimately involved in another accident, much worse, and we did make the decision....as a family...to remove life support. A very tough decision...but it was OUR decision.

In the absence of our spouses....I have appointed my daughter as having power to make medical decisions in the event that I am unable to do so. My husband has appointed his sister.

We had our attorney draw up the documents at the time we also did our trusts. In a few years, we will review all of these legal documents....WITHOUT the interference of the Goverment....thank you very much.

It bears noting that nutrician and hydration, also known as food and water, are NOT "extraordinary life saving measures." Food and water are an ordinary part of life. They are not the practice of medicine. You don't need a medical license to dispense food and water. Even when that food and water are dispensed through a tube or a straw or a bottle or through the "artificial" method of someone spoon-feeding you, it is not an extraordinary measure.

Nutrician and hydration are no more extraordinary and no more artificial than is providing hygiene or a bed or shelter.

By the way, in the interest of full disclosure and informed consent, people should know, but are rarely informed, that if you are an organ donor, the definition of death is changed for you. Specifically, if they want to harvest your heart, they will not wait until it stops beating on its own. Rather, they will declare you "brain dead," insisting that that is the same as any other kind of death, even though the heart is still beating on its own, and the only reason it is not beating when it is removed from the body is because they artificially stop it.

all doctors are extremely heroic and well intentioned, almost saintly in their demeanor and their every action

Saintly? Surely you mean that they are god-like. Many of them certainly believe themselves to be gods.

And given that many, if not most, heartily endorse a "medical procedure" that has caused the deaths of 50 million innocent lives, such a culture of death can hardly be called heroic and well-intentioned.

There are no doubt some good people still in medicine, but on the whole, the field of modern bioethics has turned it into a chamber of horrors.

Saintly? Surely you mean that they are god-like. Many of them certainly believe themselves to be gods.

Well, no. But then again, the post was intentionally over the top in that direction.

I am always amazed that some doctors can get away with this attitude around patients. A friend recently went to a new pain doctor, who told the friend to drop the surgeon who had performed a number of very successful surgeries on that friend. And, that such and such a drug was the one to take, despite it not having worked in the past.

Switched doctors in a heart beat. New one is a lot more patient and willing to work with patients. A lot.

I should add though that this can sometimes go to far. Someone I know's father has fired all the GP doctors handling Medicare cases within an hour or two drive from his house. He would diagnose himself, based on his research, and then fire the doctor if he didn't agree. It wouldn't be a problem, except that his wife has to go along.

Untrue. Insurance companies do not decide when to withdraw care. Nor does Medicaid or the VA.

Doctors sometimes do, when futility is present.

********

Yes, they do. Insurance companies will at times refuse to pay for further treatment. Medicare and Medicaid and Veterans all decide when they will and won't pay for treatment, depending on the patient's condition. I know, my father died in a VA hospital and I work for a home health care agency. I have seen people turned down for everything from home health care visits to certain treatments, depending on their condition. In fact there are a lot of things Medicare does not pay for, that is why people pay all that money for supplemental insurance.

I understand that people think this policy will mean that doctors will either refuse to give treatment or that will try and force their patients to refuse treatment based on government regulations. I get that, I just think some people are allowing their distrust of government to effect their judgment here.

Doctors are not going to turn into mass murderers because of some regulatory policy and patients are not going to turn into complete morons who are not capable of making decisions for themselves.

The truth is as long as government pays for a service, they will be involved. There is no way around that and considering how out of control medicare costs are there needs to be some attempts made to slow down the spending.

I don't like Obamacare, and I would like to see it repealed, but I think that whatever happens to that particular policy there will be some steps taken toward rationing care. Sad but true.

Professor, as long as you have designated someone to make your end-of-life care decisions on your behalf, and you know they will carry out your wishes, an advanced care directive is not necessary.

The only remaining issue to sew up is how to communicate to a hospital who that person is. Before the professor married, all of her loved ones lived far away.

But the problem is that various ideologues wish to redefine what constitutes "dying" to include more and more people who are quite alive, e.g. persons in a persistent state of unconsciousness. The problem is that they want to hasten death, to bring it before its time.

A heart lung machine will keep a corpse alive indefinitely. An older friend's dad -- guiltridden according to his son -- decided to keep his brain-dead wife's heart beating. Which it continued to do for eleven years.

I'm surprised there isn't more liberal concern about the obvious slippery-slope problem here. Helping people choose death for themselves may seem perfectly harmless, but with that dangerous precedent in place it may be a surprisingly short time before we see people choosing payday loans and Happy Meals for themselves.

it may be a surprisingly short time before we see people choosing payday loans and Happy Meals for themselves.

For years my in-laws were bombarded with offers of low-price holidays in Vegas, or cheap overnight bus trips to Indian casinos, the sponsors hoping they would feed their Social Security checks into the slot machine, bit by bit.

And the health of the elderly should be our lowest priority, after the health of children and of working adults.

And...how about withholding health care and speeding up the death of...those with lower IQ's, certain undesirable ethnic groups, people who hold subversive ideas.

What about non working adults...the cronically unemployed or those long term welfare recipients?

Cronic criminals?? Who BTW currently get carte blanche medical care. How about anyone who is in jail. They aren't working.

Gypsies, Jews.....???

At which part of this slippery slope do you think it will stop.

When I turn 65, at which time I will not consider myself a decrepit senior who is unable to make decisions, and my doctor says he wants to discuss end of life issues.....I will tell him to stuff it. That I have discussed this with my LAWYER.Actually, my doctor is more likely to want to discuss his latest elk hunting trip or his investments with me and just say we talked about end of life.

None of this, well, if we do this, it will set a precedent for something worse silliness. That something worse has been here and gone. We have been living the something worse for a while now. We don't need to wait for our own nation's T-4 Program or other official sterbehilfe policies or other programs to get rid of lebensunwertens Leben.

This "slippery slope" argument only lets the evildoers off the hook, implicitly saying that what they are doing now is not as bad as it might be. Well things rarely are as bad as they might be -- seven million Jews could have died in the Holocaust, rather than six, and it would be a rather absurd argument against Hitler to say that he should stop at number six million because it is a slippery slope.

From the 50 million innocents dead to the ESCR ghouls to the cloners and human-animal hybrid research gods to the transplant vivisectionists to the starve and dehydrate the "vegetables" because they're already dead to Barack "maybe grandma would be better off without the hip replacement" Obama, we have already descended into a chamber of horrors that is modern bio-"ethics."

Some idiot always trots out the stupid line "try to change your insurance after you get sick."

Those twits always have the insurance they deserve. You buy the insurance you want in place WHEN you're sick. Any shithead who buys the cheapest insurance available to save a few dollars when they're healthy, or who gets the 70-30 coinsurance when they could have gotten the 100-0 plan after deductibles has zero right to bitch.

These are the same people who would divorce their spouse when their spouse gets sick. It's the same reasoning.

You dance with the one that brung ya. So pick a good insurance company.

Oh, and before anyone bitches about how sometimes they don't have a choice because of their employer, that's bullshit. The only people who don't have a choice are the ones who are already sick. The only thing your employer does is pick up part of the premium. That's all. I kept my individual coverage in place even though my last employer offered group coverage.

Of course, libtards are doing their damnedest to eliminate all choice in coverage. I wish I could have a $10,000 dollar annual deductible, but libtards and other nanny statists won't allow it.

There are those today -- including those commenting here -- who would have us apologize to the likes of Dr. Karl Brandt and other physicians who led the German euthanasia programs of the 1930s and 40s. They were the ones from whom the National Socialists took many of their ideas. That's right -- the whole death machine of National Socialism originated not in the racist mind of the moronic Adolf Hitler, but in the medical profession, various medical elites who insisted that all they cared about was compassion for the suffering. Indeed, the showers at the death camps were brought over from mental hospitals, where they were first used to "provide a merciful death" to the mentally ill.

The point is not that, if we keep going, we'll soon be shoving Jews into the ovens (although a great many liberals do want to shove the Jews of Israel into the sea). The point is that we are already doing exactly the same things as pre-Holocaust Germany with the practice of medicalized death. And if they were culpable then, if those doctors were deserving of prison and the gallows back then, how can we now justify doing the same things they did or otherwise use the same arguments of "mercy killing" that they did?

Supreme Court Justice Robert H. Jackson was Chief of Counsel for the United States at Nuremberg. In United States v. Alfons Klein, et al. (the Hadamar Trial), with respect to the Hadamar psychiatric hospital, which was a site of the T-4 program, he stated, "To begin with, [the Hadamar euthanasia program] involved only the incurably sick, insane and mentally deficient patients of the Institution. It was easy to see that they were a substantial burden to society, and life was probably of little comfort to them. It is not difficult to see how, religious scruples apart, a policy of easing such persons out of the world by a completely painless method could appeal to a hard-pressed and unsentimental people. But 'euthanasia' taught the art of killing and accustomed those who directed and those who administered the death injections to the taking of human life. Once any scruples and inhibitions about killing were overcome and the custom was established, there followed naturally an indifference as to what lives were taken. Perhaps also those who become involved in any killings are not to be in a good position to decline further requests. If one is convinced that a person should be put out of the way because, from no fault of his own, he has ceased to be a social asset, it is not hard to satisfy the conscience that those who are wilful enemies of the prevailing social order have no better right to exist. And so Hadamar drifted from a hospital to a human slaughter-house.--Forward to "The Hadamar Trial (United States v. Alfons Klein, et al.)" xiv (E. Kintner, ed. 1949).

Such things wouldn't happen here?

Physician-assisted death advocate Timothy Quill has admitted, and the Ninth Circuit noted in Compassion in Dying v. Washington, 79 F.3d 790 n. 56, doctors play a role in hastening the deaths of 6,000 patients every day in this country. That is 2.2 million dead per year. The court further noted that, according to a survey by the American Society of Internal Medicine, one doctor in five said he had assisted in a patient's death. It can't happen here? It already is.

But by all means, let's not go so far as to raise the historical comparisons to the Germany of the 1930s and 40s. That would be going too far! So what if the world said "never again" back then? We are morally superior, so that what was evil for them is a good for us! -- At least that is what the pro-death people would have us believe.

They may wish to walk side-by-side with Dr. Brandt, Dr. Hermann Pfannmuller, Dr. Adolf Wahlmann, Dr. Valentin Faltlhauser, Dr. Viktor Brack, Dr. Alfons Klein, and other defendants in the Medical Trials at Nuremburg, to go along with Prof. Karl Binding and Dr. Alfred Hoche. They may wish to embrace the arguments and ideology of these physicians, but society should not.

Alex is not only a troll; he's stupid one to boot. Godwin's Law does not refer to the use of historical precedent to bolster one's argument, even when using that branch of Progressive Socialism known as National Socialism.

But the Nazis weren't very original. All the had to do was bone up on the earlier fruits of American Progressive theory; Eugenics.

You dance with the one that brung ya. So pick a good insurance company.

Indeed. The whole point of insurance is to buy it BEFORE you get sick. It doesn’t make any mathematical sense to allow people to buy insurance only when they are sick.

various medical elites who insisted that all they cared about was compassion for the suffering. Indeed, the showers at the death camps were brought over from mental hospitals, where they were first used to "provide a merciful death" to the mentally ill.

I think this is one of the lesser told stories of the Nazi state. I just watched a documentary on it and although I think I knew that there was euthanasia, the extent of it never really struck me before. And the pictures of the patients that were killed were so, so sad.

We as a society, can not make decisions on who has the right to live. We should always be careful when people start talking like that.

When the Government begins picking and choosing who gets to have medical care...AND when that picking and choosing is based not on individual medical necessity or even on medical best practices, we are heading down a very dark and dangerous path.

RIPIC, (I think it was) said we should concentrate our medical efforts/dollars on the young and the gainfully employed.

I admit to having an analytical mind and have used my financal planning skills to help my clients get the best bang for the buck. Cost benefit analysis is important in business and investing.

Looking strictly at the cost benefit analysis, it would make actuarial sense to eliminate treatement for certain people with certain illnesses.

However, at what price is our soul to be sold for cost savings??

If I or my family want to choose not to have treatement, it is my choice. If my doctor should advise me that continued treatments for my conditions are futile, I can take that under advisement.

However, when the government is singling out an entire group of people for cost benefit ELIMINATION, we all should be very very afraid.

Right now, the targeted group is Seniors. People over age 65. People who have had long productive lives behind them and probably another 2 to 3 decades ahead. But...because they are not the 'favored' group, they are targeted by the government to die.

Who will be the next group to be targeted for reduced care/elimination? The inconvenient political opposition? Ethnic groups that are not in favor? Those who are consuming more resources than they are producing? The mentally challenged? Who?

The ultimate result of RICPICs thought is that no one would be safe from elimination by the government machine if it suits the ruling powers.

"We have seen more than once that the public welfare may call upon the best citizens for their lives. It would be strange if it could not call upon those who already sap the strength of the State for these lesser sacrifices, often not felt to be such by those concerned, in order to prevent our being swamped with incompetence. It is better for all the world, if instead of waiting to execute degenerate offspring for crime, or to let them starve for their imbecility, society can prevent those who are manifestly unfit from continuing their kind. . . . Three generations of imbeciles are enough."

I blame a lot of this bullshit on that fat fucking wellness quack Andrew Weil. He started a lot of this wellness bullshit and convinced enough leftards at his seminars and in power that his quackery works. Now look at what we have.

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